The importance of any surgical detail. The surgical technique of suturing the uterus during cesarean section

Cesarean section (CS) rates have risen substantially and now represent the most frequently performed abdominal surgical procedure. This increase has been accompanied by a parallel rise in operative and postoperative complications. Despite its widespread use, CS technique remains highly heterogeneous across countries, hospitals, and even among obstetricians working in the same departments. Surgical standardization has the potential to reduce complications and improve both short- and long-term outcomes. Among the most controversial technical aspects of CS are the level of the uterine incision in the lower uterine segment (LUS), the use of single- versus double-layer closure of the uterine wall, and the caliber of the needle used for suturing. These elements therefore need critical evaluation, as they are important for uterine healing, scar integrity, and outcomes in subsequent pregnancies. The level of the uterine incision is particularly important, as lower incisions involve a higher proportion of fibrous tissue and less muscular tissue, which is important for the scar tensile strength and promote optimal healing. In this article, these three components are examined, and based on clinical experience and histology knowledge, a rational, standardized surgical approach is proposed. Lower LUS incisions incorporating predominantly fibrous tissue will result in a stronger uterine scar. Single-layer uterine closure minimizes retained suture material while providing adequate mechanical support, and the use of larger caliber needles reduces the amount of the remained suture material, thereby limiting foreign-body reactions. Standardization of these aspects of CS technique may improve surgical outcomes, enhance uterine scar quality, and will enable meaningful comparisons among clinical studies.